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RAI - MRCP > Rheumatology > Flashcards

Rheumatology Flashcards

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1
Q

What are the common associations with Ankylosing Spondylosis

A

A’s

Ant Uveitis
Aortic Regurgitation
Apical Fibrosis
AV nodal block
Achilles Tendonitis
Amyloids
Quada Equina

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2
Q

What HLA is associated with Ankylosing Spondylosis

A

HLA-B27

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3
Q

What are the Ix for diagnosing Ankylosing Spondylosis

A

Shobers Test

Xray;
Bamboo spine
Syndesmophytes
Sacroilities
Squaring of vertebral

CXR: Apical Fibrosis

Spirometry - restrictive pattern

Mx:
Exercise, swimming
NSAID
Physio
Anti-TNF ( Etanercept, Adalimumab)

Note:
Antirheumatoid frugs such as Sulfazalsine only used if peripheral joint inv. present

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4
Q

What is the Ix and Mx of Antiphospholipid Syndrome

A

Ix;
Prolonged APTT
Thrombocytopenia
Test for;
Anti-Cardiolipin
Anti-Beta2 glycoprotein
Lupus anticoagulant

Mx:
Primary VTE prophylaxis - Asprin
LMWH + Aspirin if high risk
( pregnant )

Secondary ;
Life long Warfarin ; INR 2-3
If clots , when on warfarin;
Add Aspirin + Warfarin ( INR 3-4)

If arterial thrombus ;
Warfarin ( INR 2-3)

INR pregnancy
LMWH + Aspirin

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5
Q

What are the risk factors for Avascular necrosis of Hip

A

Long term steroids
Chemo
Alcohol
Trauma

MX:
Hip replacement

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6
Q

What skin cancer is Azathioprine usually associated with

A

Non Melanoma Skin cancers

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7
Q

What HLA is associated with Behcets

A

HLA - B51

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8
Q

What is the triad of behcets

A

Oral ulcers
Genital ulcers
Anterior Uveitis

Note:
Erythema nodosum is also seen
High risk of clots and thrombophelibitis
Neuro inv.
GI upset

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9
Q

What is pathergy test and where is it used

A

Puncture site with needle becomes inflamed and pustule formed

Behcets +ve

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10
Q

What are the common disorders and its lab values

A
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11
Q

Proximal muscle weakness
Rash in shoulders and back ( Shawl sign)
rash around eyes ( Heliotropic rash)
Thickened knuckles ( Guttorns)

Whats Is your Dx

A

Dermatomyositis

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12
Q

What are the common association complication of dermatomysotis

A

Cancer
( Breast, Lung, Ovaries)

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13
Q

What blood Ix for Dermatomyositis

A

(around 80%) are ANA positive

around 30% of patients have antibodies to
-aminoacyl-tRNA synthetases (anti-synthetase antibodies),
including:
-antibodies against histidine-tRNA ligase (also called Jo-1)
-antibodies to signal recognition particle (SRP)

-anti-Mi-2 antibodies ( Most important)

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14
Q

What is the Mx of Dermatomyositis

A

Steroids

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15
Q

What is ;
Diffuse idiopathic skeletal hyperostosis

A

relatively common finding of ossification at sites of tendinous and ligamentous insertion of the spine. It tends to be seen in elderly patients.

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16
Q

What is the Ix for Discitis

A

MRI spine
CT guided biopsy
Blood cultures

Most common; Staph Aureus

Pt. should also be Ix for IE ( TOE/TTE)

MX:
Abx for 8 week

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17
Q

What is the Mx of Discoid Lupus

A

Topical Steroids
Oral Hydroxychloroquine
Avoid Sun exposure

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18
Q

Where do you angiod retinal streaks

A

Ehler Danlos

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19
Q

What are the cardiac associations of Ehler Danlos ( autosomal dominant)

A

Aortic Regurg
MVP
Aortic dissection

Note:
Easy bruising
Fragile skin
Hyper-elastic - recurrent dislocations
SAH

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20
Q

What group is commonly afftected by FMF

A

It is more common in people of Turkish, Armenian and Arabic descent.

Note:
Features - attacks typically last 1-3 days
pyrexia
abdominal pain (due to peritonitis)
pleurisy
pericarditis
arthritis
erysipeloid rash on lower limbs

Management
colchicine may help

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21
Q

if uric acid level < 360 umol/L during a flare and gout is strongly suspected, What do you do

A

repeat the uric acid level measurement at least 2 weeks after the flare has settled

Note;
If Uric Acid >/= 360 umol/L - It confirms gout

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22
Q

What is the synovial fluid analysis in Gout

A

needle shaped negatively birefringent monosodium urate crystals under polarised light

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23
Q

What is the Mx of gout

A

In acute flare; (uric acid > 0.45 mmol/l)

> NSAID ( use PPI cover)
Colchicine
( used with caution in renal impairment: the BNF advises to reduce the dose if eGFR is 10-50 ml/min and to avoid if eGFR < 10 ml/min )
oral steroids may be considered if NSAIDs and colchicine are contraindicated.
a dose of prednisolone 15mg/day is usually used
another option is intra-articular steroid injection

2 weeks after;
Start Urate lower therapy;
Alopurinol

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24
Q

What is the 2nd line Urate lowering therapy if Allopurinol Contrainicated/ Not tolerated

A

Febuxostat

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25
Where do you see Juvenile Idiopathic Arthritis
arthritis occurring in someone who is less than 16 years old that lasts for more than three months. Note; associated with +ve ANA and anterior uveitis
26
Langerhans cell histiocytosis
Features >bone pain, typically in the skull or proximal femur >cutaneous nodules >pituitary involvement: leads to diabetes insipidus due to pituitary stalk involvement >pulmonary involvement: More >common in adults, presenting with dyspnoea, cough, and chest pain >recurrent otitis media/mastoiditis tennis racket-shaped Birbeck granules on electromicroscopy
27
Pain and tenderness localised to the lateral epicondyle Pain worse on wrist extension against resistance with the elbow extended or supination of the forearm with the elbow extended. What is your Dx
Lateral Epicondylitis
28
Unilateral or bilateral leg pain (with or without back pain), numbness, and weakness which is worse on walking. Resolves when sits down. Pain may be described as 'aching', 'crawling'. What is your Dx
Spinal Stenosis
29
positional element to the pain. Sitting is better than standing and patients may find it easier to walk uphill rather than downhill.
Lumbar Spinal Stenosis Ix: MRI Mx: Laminectomy
30
What gene is affected in Marfans
FBN1
31
muscle pain and stiffness following exercise muscle cramps second wind phenomenon
McArdle Syndrome ( autosomal recessive)
32
What are the Ix finding of McArdle Syndrome
rhabdomyolysis & myoglobinuria low lactate levels during exercise
33
How long should women avoid pregnancy after stropping methotrexate
at least 6 months after treatment has stopped
34
What will you monitor when someone is on Methotrxate
FBC, U&E and LFTs
35
What Abx should you avoid when someone is on MTX
Trimethoprim and Co-Trimoxazole
36
What are the common causes of myopathies
inflammatory: polymyositis inherited: Duchenne/Becker muscular dystrophy, myotonic dystrophy endocrine: Cushing's, thyrotoxicosis alcohol Note: Key Features ; Features symmetrical muscle weakness (proximal > distal) common problems are rising from chair or getting out of bath "sensation normal, reflexes normal, no fasciculation"
37
What are some examples of NSAID
Examples of NSAIDs include ibuprofen diclofenac naproxen aspirin
38
What is the mx of OA
>oral analgesia >intra-articular injections: provide short-term benefit >total hip replacement remains the definitive treatment
39
What are X-ray changes of osteoarthritis
(LOSS) Loss of joint space Osteophytes forming at joint margins Subchondral sclerosis Subchondral cysts
40
presents in childhood fractures following minor trauma blue sclera deafness secondary to otosclerosis dental imperfections are common
Osteogenesis Imperfecta ( Autosomal Dominant) abnormality in type 1 collagen Ix; Investigations adjusted calcium, phosphate, parathyroid hormone and ALP results are usually normal in osteogenesis imperfecta
41
What are the key features of osteomalacia
Low Ca due to Low Vit D Features bone pain bone/muscle tenderness fractures: especially femoral neck proximal myopathy: may lead to a waddling gait Investigation bloods low vitamin D levels low calcium, phosphate (in around 30%) raised alkaline phosphatase (in 95-100% of patients) Treatment vitamin D supplmentation a loading dose is often needed initially calcium supplementation if dietary calcium is inadequate
42
x-ray translucent bands (Looser's zones or pseudofractures) What is your Dx
Osteomalacia
43
What are the common causes of osteomyelitis
Microbiology Staph. aureus is the most common cause except in patients with sickle-cell anaemia where "Salmonella species" predominate Note: Non diabetic + Puncture wound - Pseudomonas Diabetic + Puncture wound - Staph Aureus Implant related infection - Coag -ve Staph Mx: Management flucloxacillin for 6 weeks
44
What is the mx of Osteomyelitis if Pt. is Pen allergic
clindamycin if penicillin-allergic
45
Pt. with sickle cell has osteomyelitis What is the common organism
sickle-cell anaemia where "Salmonella species" predominate
46
Bone pain; But Ca; Po, APT, PTH all normal
Osteopetrosis (marble bone disease) Mx: stem cell transplant interferon-gamma
47
How do you assess ; Osteoporosis: Assessing patients following a fragility fracture
>/=75 and has a fragility fracture ( Directly start Tx ; no need for DEXA) if <75; DEXA
48
When do you offer DEXA scan even prior to assessing fragility scores
> 50 years of age with a history of fragility fracture < 40 years of age who have a major risk factor for fragility fracture - these patients should be referred to a specialist depending on the T-score before starting treatments that may have a rapid adverse effect on bone density (for example, sex hormone deprivation for treatment for breast or prostate cancer)
49
What are common fragility fractures sites
Vertebrae (most common) Hip (proximal femur) Distal radius (Colles' fracture) Proximal humerus
50
What is the threshold to start TX based on DEXA scan
T-score of - 2.5 SD or below
51
Bone pain Isolated ALP rise
Paget disease Features; bowing of tibia, bossing of skull Bone scintigraphy increased uptake is seen focally at the sites of active bone lesions Mx: Bisophosphonates Calcitonin if above Is not tolerated
52
Raised procollagen type I N-terminal propeptide (PINP) serum C-telopeptide (CTx) urinary N-telopeptide (NTx) urinary hydroxyproline Where do you see it
Pagets disease
53
What are the key features of PAN
vasculitis affecting medium-sized arteries with necrotizing inflammation leading to aneurysm formation. Features fever, malaise, arthralgia weight loss hypertension mononeuritis multiplex, sensorimotor polyneuropathy testicular pain livedo reticularis haematuria, renal failure p-ANCA +ve hepatitis B +ve Ix: Angiogram showing microanuerysms
54
What are the key features of PMR
Features typically patient > 60 years old rapid onset (e.g. < 1 month) aching, morning stiffness in proximal limb muscles NO weakness also mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, night sweats Investigations raised inflammatory markers e.g. ESR > 40 mm/hr note CK and EMG normal Treatment prednisolone e.g. 15mg/od patients typically respond dramatically to steroids, failure to do so should prompt consideration of an alternative diagnosis Note: PMR can be associated with GCA
55
What are the key features of polymyositis
Features proximal muscle weakness +/- tenderness Raynaud's respiratory muscle weakness interstitial lung disease e.g. fibrosing alveolitis or organising pneumonia seen in around 20% of patients and indicates a poor prognosis dysphagia, dysphonia Investigations elevated creatine kinase other muscle enzymes (lactate dehydrogenase (LDH), aldolase, AST and ALT) are also elevated in 85-95% of patients EMG muscle biopsy anti-synthetase antibodies anti-Jo-1 antibodies are seen in pattern of disease associated with lung involvement, Raynaud's and fever Management high-dose corticosteroids tapered as symptoms improve azathioprine may be used as a steroid-sparing agent
56
What are the key differences between PMR and Polymyositis
PMR: Proximal Muscle stiffness/Pain Normal CK Raised ESR Rapid onset <1month Can be associated with GCA Mx: Low dose steroids 15mg/kg Polymyositis; Proximal Muscle Weakness +/- Pain Raised CK +++ Anti- Jo Abs Ix: Muscle Biopsy, EMG Mx: High Dose steroids
57
What are the common associations of Psuedogout
haemochromatosis hyperparathyroidism low magnesium, low phosphate acromegaly, Wilson's disease
58
What is the synovial fluid analysis of Pseudo gout
weakly-positively birefringent rhomboid-shaped crystals Xray; Chondrocalcinosis Mx; aspiration of joint fluid, to exclude septic arthritis NSAIDs or intra-articular, intra-muscular or oral steroids as for gout
59
What are the key features of psoriatic arthritis
Symmetrical DIP Skin Rash Nail ; Pitting and onycholysis Arthritis Mutilans
60
What is the X-ray features of psoriatic arthritis
pencil-in-cup' appearance
61
What is the Mx of Renaud's Phenomenon
first-line: calcium channel blockers e.g. nifedipine IV prostacyclin (epoprostenol) infusions: effects may last several weeks/months
62
What type of cryoglobinemia is associated with Reynauds
Type I
63
What is the key triad of Reactive arthritis
Ant. Uveitis Joint pain ( assymetircal, lower limbs) Urethritis Post infection; Salmonella, Chlamydia Dry Tap - -ve culture of synovial fluid
64
What skin rash is associated with Reactive Arthritis
keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles)
65
What is the Mx of Relapsing Polychondritis
Induce remission: steroids Maintenance: azathioprine, methotrexate, cyclosporin, cyclophosphamide
66
Ears: auricular chondritis, hearing loss, vertigo Nasal: nasal chondritis → saddle-nose deformity Destruction of cartilage What is your Dx
Relapsing Polychondritis
67
What are the extra-articular manifestations of Sarcoid
Respiratory: pulmonary fibrosis, pleural effusion, pulmonary nodules, bronchiolitis obliterans, methotrexate pneumonitis, pleurisy ocular: keratoconjunctivitis sicca (most common), episcleritis, scleritis, corneal ulceration, keratitis, steroid-induced cataracts, chloroquine retinopathy osteoporosis ischaemic heart disease: RA carries a similar risk to type 2 diabetes mellitus increased risk of infections depression Less common Felty's syndrome (RA + splenomegaly + low white cell count) amyloidosis
68
What is the Dx marker of RA
Anti-CCP
69
What is the Mx of RA
For acute flare; Steroids DMARDS; +/- bridging steroids 1st line - Methotextrate; If Fails; Try another DMARD's sulfasalazine leflunomide hydroxychloroquine If 2 DMARD's Fail; Then trial Anti-TNF etanercept infliximab adalimumab Rituximab anti-CD20 monoclonal antibody,
70
What are the common causes of Septic Arthritis
Staph Aureus - most common In young adults who are sexually active- Nesirrhoea Gonorrhea Mx: Fluclox/ Clindamycin ( 4-6 weeks) Can switch to oral Abx after 2 weeks of IV
71
What are the Ix of septic arthritis
Synovial fluid sampling ( Before Abx Tx) >shows a leucocytosis with neutrophil predominance >gram staining is negative in around 30-50% of cases >fluid culture is positive in patients with non-gonococcal septic arthritis >blood cultures: the most common cause of septic arthritis is hematogenous spread >joint imaging
72
Painful arc of abduction between 60 and 120 degrees Tenderness over anterior acromion
Supraspinatus tendonitis
73
Where do you see +ve Anti Ro and Anti-La
Sjogrens Note: RF can be +ve as well Ix: Schimers test Parotid gland biopsy (focal lymphocytic infiltration) hypergammaglobulinaemia, low C4 Mx; Management artificial saliva and tears pilocarpine may be helpful to stimulate saliva production
74
Arthralgia Salmon Pink Rash Fever ( which spikes in afternoon to evenings) which accompanies joint pain What is your Dx
Adult onset Stills Disease Mx; >NSAIDs should be used first-line to manage fever, joint pain and serositis they should be trialled for at least a week before steroids are added. >steroids may control symptoms but won't improve prognosis >If symptoms persist, the use of methotrexate, IL-1 or anti-TNF therapy can be considered
75
What are the key Ix of SLE
Antibodies 99% are ANA positive this high sensitivity makes it a useful rule out test, but it has low specificity 20% are rheumatoid factor positive anti-dsDNA: highly specific (> 99%), but less sensitive (70%) anti-Smith: highly specific (> 99%), sensitivity (30%) also: anti-U1 RNP, SS-A (anti-Ro) and SS-B (anti-La) Note: anti-dsDNA titres can be used for disease monitoring Note: Complement levels are low during active disease
76
What is the Mx of SLE
NSAIDs sun-block Hydroxychloroquine the treatment of choice for SLE
77
anti-scl-70 antibodies associated with
diffuse cutaneous systemic sclerosis associated with a higher risk of severe interstitial lung disease
78
anti-centromere antibodies associated with
limited cutaneous systemic sclerosis/CREST ( Pulm HTN)
79
GCA with vision problems
IV methyl pred x 3 days followed by oral pred (1mg/kg ) ~ 100-160mg/day
80
GCA without vision problems
High dose oral pred ( 60mg/day)
81
What are the key Ix of GCA
Temporal artery biopsy - Skip lesions seen Raised inf markers and ESR Normal CK and EMG
82
What is Finkelstein test used in
DeQuervains Tenosynovitis ( Class thumb in palm within fingers and ulnar deviate -> Causes pain)
83
What are the key features of Takayasu's arteritis
Large/medium vessel arteritis Affects Aorta and its branches Fever Malaise Weight loss TIA/ Stroke MI/ Claudication Ix; Raised ESR, CRP , CT-A Mx: Steroids with addition of MTX/ Azathioprine
84
Pigmentation of urine, eye, connective tissue Cartilage pigmentation ( Ochronosis) Urine after standing becomes dark Bone pains What is your Dx
Alkaptonuria
85
What Abs are +ve in Drug Induced Lupus
Anti-Histone Abs
86
If DEXA shows <-4.5 or who have 2 or more fragility fractures what is the 1st line mx
Teriparatide
87
What are the eye Ix features of Stills disease
Leucocytosis Thrombocytosis Increased Ferritin Increased ESR Increased CRP All Auto-Abs will be NEGATIVE
88
Which Abs will likely be +ve in Scleroderma Rena Crisis with skin inv
Anti RNA Polymerase III Abs
89
What are the key features of Pseudo-Hypoparathyroidism
Shortening of 5th Metacarpal Hypocalcaemia
90
What is +ve Shimmers test
<5mm wetting In 5mins
91
What is the DEXA cutoff for starting Osteoporosis Mx in someone taking long term steroids
<-1.5
92
Purpuric rash , Renauds, Polyarthralgia +ve RF +ve ANA Low complement ( c4) Normal C3 What is your Dx
Cryoglobunemia
93
Where do you see +ve Anti RNP abs
Mixed Connective Disease
94
What is the Mx of Pulm HTN in SS
Iloprost infusion +/- Sildneafil

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